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<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
<br />CHECK if BILLING ADDRESS
<br />FACILITY ID #
<br />?%�C ECE�V �D
<br />SERVICE REQUEST #
<br />HOME or MAILING ADDRESS
<br />PO BOX 801
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<br />OWNER / OPERATOR
<br />CITY Gilbert
<br />CHECK if BILLING ADDRESS
<br />FACILITY NAME Foothill Sanitary Landfill
<br />DATE: ��/2-
<br />ASSIGNED TO: (� L /3 p ( EMPLOYEE
<br />SITE ADDRESS 64.84
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<br />Fee Amount: '139-0
<br />Waverly Rd.
<br />Payment Date
<br />Linden
<br />95236
<br />Street Number
<br />Directlon
<br />Received By:
<br />Street Name
<br />city
<br />Zip Code
<br />HOME or MAILING ADDRESS (If Different from Site Address)
<br />1810
<br />E. Hazelton Ave.
<br />Street Number
<br />Street Nam
<br />CITY Stockton
<br />STATE CA ZIP 95205
<br />PHONE #1 Exr.
<br />APN #
<br />LAND USE APPLICATION #
<br />(,209 ) 468-3066
<br />093-440-02
<br />PHONE#2 ExT•
<br />BOS DISTRICT
<br />LOCATION CODE
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUESTOR
<br />CHECK if BILLING ADDRESS
<br />BUSINESS NAME
<br />Yellow Jacket Drilling
<br />?%�C ECE�V �D
<br />PHONE#
<br />(909)989-8563
<br />HOME or MAILING ADDRESS
<br />PO BOX 801
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<br />7/rr-i, �,-+-
<br />FAX #
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<br />(909 )944-9301
<br />CITY Gilbert
<br />STATEAZZIP 85299 '
<br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same,
<br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project
<br />or activity will be billed to me or my business as identified on this form.
<br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN
<br />COUNTY Ordinance Codes, Standards, STATE and FEB�w
<br />l
<br />APPLICANT'S SIGNATURE: DATE: lag 1 f7�
<br />PROPERTY / BUsiNESS OwNER❑ OPERATOR/ MANAGEROTER AUTHORzEAGENT Q15700
<br />IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title
<br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the
<br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment
<br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is
<br />provided to me or my representative.
<br />TYPE OF SERVICE REQUESTED: S, �Vel, '`C
<br />COMMENTS: 71241/l - G���L �Y' . Q,► (J.�L '�vC{ e -i(,-°, �A G - ///¢ iL�
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<br />?%�C ECE�V �D
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<br />44N 2016
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<br />ACCEPTED BY: � � Sal 3 /I� ;,t `� Yl/
<br />EMPLOYEE #: 41d
<br />DATE: ��/2-
<br />ASSIGNED TO: (� L /3 p ( EMPLOYEE
<br />DATE: I e// 2- Ile'
<br />Date Service Completed (if already completed): 3/ SERVICE CODE: IE:
<br />Fee Amount: '139-0
<br />Amount Pai 3�0. 6D
<br />Payment Date
<br />4/,3//6
<br />Payment Type �
<br />Invoice #
<br />Chk # �j� ��57
<br />Received By:
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<br />EI D 48-02-025 y/'2 - UCitc fvr ate^ w r ��"�'^ S6 -/I'F - ,+c �t - $R FORM (Golden Rod)
<br />REVISED 11/17/2003 ,c7/q _04 7Arl
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